ReviewDiabetes self-management in patients with low health literacy: Ordering findings from literature in a health literacy framework
Introduction
Self-management has become increasingly important in the treatment of diabetes mellitus type 2 (DM2). Patients with DM2 have become partners in the treatment of their own disease and self-management is crucial to obtain adequate glycaemic control. There is no universally accepted definition of self-management. Barlow et al. defined general self-management as the patient's ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic disease [1]. Diabetes self-management is generally divided into four domains: nutritional management; exercise and physical activity; blood glucose monitoring; and medication utilization [2], [3], [4]. The American Association of Diabetes Educators (ADEE) operationalized nutritional management into making healthy food choices, understanding portion sizes and learning the best times to eat. Regular activity is important for overall fitness, weight management and blood glucose control. Together with healthcare professionals, patients should address barriers to regular physical activity and develop an appropriate plan to balance food and medication with the activity level. The AADE also note that daily self-monitoring of blood glucose provides patients with diabetes the information they need to assess how food, physical activity and medications affect their blood glucose levels. To adequately utilize medications, patients should be knowledgeable about each medication, including its action, side effects, efficacy, toxicity, prescribed dosage, appropriate timing, frequency of administration, effect of missed/delayed doses and instructions for storage, travel and safety [5].
To implement optimal diabetes self-management, patients must apply specific knowledge and decision-making skills across the multiple domains of self-management. This requires adequate health literacy (HL). The Institute of Medicine (IOM) defined HL as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions [6]. Subjects with low HL tend to be less likely to successfully manage chronic diseases [7], [8]. They generally have less knowledge about their disease, exhibit inadequate self-management and have poor health outcomes [9], [10], [11], [12], [13], [14].
In 2007 Paasche-Orlow and Wolf developed a framework that outlined routes through which HL might affect health actions in the access and utilization of health care, patient–provider interactions and self-management [15]. Drawing upon these ideas, von Wagner et al. developed a framework for health literacy and health actions that was derived from health psychology (Fig. 1) [16]. This framework was developed to guide research on the processes through which HL affects health outcomes. The framework proposes that health actions (access and use of health care, patient–provider interactions, and the management of health and illness, e.g. diabetes self-management) determine health outcomes (e.g. HbA1c level) through sociocognitive motivational and volitional determinants. Motivational determinants include traditional social cognition constructs (e.g. beliefs and attitudes) which in turn are associated with access to health information and knowledge. For example, adequate knowledge in diabetes self-management consists of knowing the effect of food on blood glucose. Volitional determinants on the other hand refer to objective and subjective (e.g. self-efficacy) action control and include task-specific skills, such as information processing and navigational skills to acquire specific knowledge about adherence regimens, and cognitive skills (e.g. anticipate on glucose levels). The motivational and volitional determinants are not affected by levels of HL alone, but form a symbiotic relationship with external system factors. For example accessibility of health care information, communication skills of the health care provider, and out-of-pocket costs for health care. The motivational determinant ‘patient's understanding of a healthy diet’ also depends on how well the healthcare provider is able to explain what the patient should or should not eat to maintain a healthy diet [16].
The aim of this paper is to review the literature on the association between HL and diabetes self-management, and the possible mediating variables in this pathway. A secondary aim is to order the findings in the framework proposed by von Wagner et al. In the Section 2 we explain why we chose this framework to order our literature findings and describe the methods for our literature review. The findings of our literature review are schematically reported in the Section 3. The paper ends with a discussion of the findings and implications for further research.
Section snippets
Literature review
In July 2011, we searched for articles on HL, diabetes, diabetes self-management and its four domains (nutritional management; exercise and physical activity; blood glucose monitoring; and medication utilization). Relevant search terms were derived from literature on HL and diabetes self-management [9], [10], [11], [12], [13], [14]. We used the following keywords and Medical Subject Headings (MeSH) to search in PubMed:
[Health literacy or literacy or numeracy] and [diabetes] and [self-management
Results
In this section we first summarize the content and methodological quality of the papers that were included in our review (Section 3.1). We then describe findings on the association between HL and diabetes self-management (Section 3.2). We end with findings on possible mediating variables in the association between health literacy and self-management, divided into motivational and volitional determinants (Section 3.3). Fig. 3 presents a schematic ordering of the findings in von Wagner's
Discussion and conclusion
Below we discuss the main findings in this literature review and describe various gaps in research on HL and diabetes self-management. The discussion ends with a reflection on strengths and weaknesses of this study. The discussion is followed by a general conclusion and implications for further research.
Conflicts of interest
The authors have no conflicts of interest to declare.
Acknowledgements
The authors thank Petra Jellema for her constructive comments on this review.
References (38)
- et al.
Self-management approaches for people with chronic conditions: a review
Patient Educ Couns
(2002) - et al.
Health literacy and knowledge of chronic disease
Patient Educ Couns
(2003) - et al.
The impact of health literacy on self-monitoring of blood glucose in patients with diabetes receiving care in an inner-city hospital
J Natl Med Assoc
(2010) - et al.
Literacy-appropriate educational materials and brief counseling improve diabetes self-management
Patient Educ Couns
(2009) - et al.
The level and determinants of diabetes knowledge in Kuwaiti adults with type 2 diabetes
Diabetes Metab
(2009) - et al.
The relationship between health literacy and knowledge improvement after a multimedia type 2 diabetes education program
Patient Educ Couns
(2009) - et al.
Health literacy and self-efficacy for participating in colorectal cancer screening: the role of information processing
Patient Educ Couns
(2009) - et al.
Monitoring in diabetes self-management: issues and recommendations for improvement
Popul Health Manag
(2011) - et al.
The summary of diabetes self-care activities measure: results from 7 studies and a revised scale
Diabetes Care
(2000) - et al.
Measuring diabetes self-care: a psychometric analysis of the self-care inventory-revised with adults
Diabetes Care
(2005)
Introduction
Literacy and health outcomes: a systematic review of the literature
J Gen Intern Med
Health literacy and child health outcomes: a systematic review of the literature
Pediatrics
Health literacy and diabetic control
J Amer Med Assoc
The relationship between literacy and glycemic control in a diabetes disease-management program
Diabetes Educ
Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program
J Amer Med Assoc
Association of health literacy with diabetes outcomes
J Amer Med Assoc
A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]
BMC Health Serv Res
Cited by (100)
Cognitive Behavioral Therapy for self-care behaviors with type 2 diabetes mellitus patients: A systematic review
2022, Diabetes and Metabolic Syndrome: Clinical Research and ReviewsCitation Excerpt :The original version of the self-care behavior assessment tool comprised 12 items that assessed five components of diabetes self-care: general diet, special diet, exercise/physical activity, medication, and blood glucose checks [48]. Self-care behaviors comprise physical activity, dietary patterns, weight management, self-monitoring of blood glucose, and medication compliance [49]. In contrast to the findings of this review, the DSCBA instrument, which assesses the overall self-care behaviors using 14 assessment items, is more effective in assessing self-care behaviors.
The effect of health literacy-based, health belief-constructed education on glycated hemoglobin (HbA1c) in people with type 2 diabetes: A randomized controlled study
2022, Primary Care DiabetesCitation Excerpt :The framework defining the relationship between HL and health behavior developed based on the Paasche-Orlow and Wolf approach by von Wagner reveals that HL levels are affected by access to and use of healthcare services by patients, patient health professional communication, disease management, self-care skills, and care outcomes [23,24]. Studies with patients with type 2 diabetes determined that the HL levels of patients affected self-efficacy levels and that paying attention to the patient's health literacy level was an effective strategy to develop self-efficacy [16,25]. Educational interventions based on the HBM for patients with diabetes appear not to merely pay attention to HL levels [18,19].
Factors Influencing the Health Behavior During Public Health Emergency: A Case Study on Norovirus Outbreak in a University
2021, Data and Information ManagementA patient caregiver survey in Indonesia: Knowledge and perception of antibiotic use and microbial resistance
2020, Journal of Infection and Public Health